Training in the management of ano-rectal disease is inadequately addressed in many fellowship training programs. As a result, conditions such as hemorrhoids, acute hemorrhoid thrombosis, anal fissures, anal pruritus, and stool incontinence which are treatable in the office, are referred to the surgeon. Decompression of an acute thrombosed hemorrhoid is easily performed in the office. Attached is a video demostrating how easy and quickly this is achived.

We present a 28 year old pregnant lady at 28 weeks gestation who developed significant rectal pain about 48 hours previously. She had a history of grade 2 internal, and external hemorrhoids on previous anoscopic examination for which she had been prescribed fiber, stool softner and preperation-H ointment. Her symptoms had started abruptly following straining during a bowel movement. The patient was in severe throbbing pain and could not sit due to her pain. On examination she had a very tender thrombosed external hemorrhoid that measured 1cm x 2cm. Following informed consent the hemorrhoid was infiltrated with 1% lidocaine and incised to release a blood clot. This incision is made in an oval or triangular shape to leave a gaping wound so that it does not close over and allow another clot to form. The patient got immediate relief of her pain and was most grateful.

As the video demonstrates this is a quick and easy procedure. There is a 72 hour window from the start of symptoms in which to perform the incision and drainage. Referral to a surgeon could result in missing this window. After 72 hours the clot starts to organize and drainage is not possible. Treatment then is with analgesia and sitz baths etc. and recovery takes a few weeks. This patient will most likely need hemorrhoid banding following delivery of her baby to reduce the risk of this happening again in her next pregnancy. An ano-rectal clinic should be part of any gastroenterology practice providing comprehensive care.